Supporting the Continuum of Palliative Care: A Resource ......Data and Analytics • Claims • Rx...
Transcript of Supporting the Continuum of Palliative Care: A Resource ......Data and Analytics • Claims • Rx...
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August 20, 2019
Supporting the Continuum of Palliative Care: A Resource Hub for State
Policymakers
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Welcome, Introductions, and Overview
Kitty Purington, NASHPScott Bane, The John A. Hartford Foundation
Supporting the Continuum of Palliative Care: A Resource Hub for State
Policymakers
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Priority Areas
FamilyCaregiving
Age-Friendly Health Systems
SeriousIllness
&End of Life
Scott BaneProgram Officer
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Who We Are
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Improving the Health of Older Adults
amount invested in aging and health since 1982
$13,880,000 + in Palliative Care & EOL
$ 585,000,000
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• Focuses on improving the quality of life for people facing serious illness:
̶ Pain & symptom management̶ Communication & coordinated care̶ Appropriate from time of diagnosis̶ Can be provided w/ curative treatment
Palliative Care
Resource: Center to Advance Palliative Care www.CAPC.org
http://www.capc.org/
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NASHP:Supporting the Continuum of Palliative Care
Goal of GrantImprove access to and the quality of hospital and community-based palliative care services
Approach • Review palliative care activity & policies in states• Convene State Leadership Council on Palliative Care• Develop briefs for State Health Policymakers• Provide technical support to states• Disseminate findings and resources
www.johnahartford.org www.nashp.org
http://www.johnahartford.org/http://www.nashp.org/
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NASHP’s Palliative Care Work
NASHP received funding from The John A. Hartford Foundation to conduct a 26-month project focusing on opportunities and challenges for states to advance palliative care programs/policies.
Goal of this project: to support state leaders in their work to expand access to, and quality of, palliative care. Convene state leaders Understand current state activity Develop resources and recommendations Provide support to states that are working on these issues
https://www.johnahartford.org/
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Why Palliative Care?
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What is palliative care?
’ Interdisciplinary, patient- and family-centered health care that addresses the physical, mental, social, and spiritual well-being of seriously ill individuals
’ Provided in facility, outpatient, community, or home settings
’ Provided alongside curative care, if desired by patient (distinct from hospice)
’ Not limited to individuals with a terminal illness
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Palliative Care & States
Palliative care and the Triple Aim: Improving the individual experience of care;Improving the health of populations; and Reducing the per capita costs of care for populations.
Alignment of state policy goals to foster high quality, value-driven care for high-cost-high needs populations, such as: Patient-centered care models; Value-base purchasing; Long-term services and supports rebalancing.
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National Scan Finding: While the majority of states have not developed a comprehensive policy strategy, many states are taking steps to increase access to and quality of palliative care.
Domains of Policy Activity:
--Implementing regulation;
--Instituting public insurance coverage and reimbursement;
--Promoting public awareness.
States identified with palliative care policy activity
VA
NH MA
ME
NJCT
RI
DE
VT
NY
DCMD
NC
PA
WV
FL
GA
SC
KY
INOH
MI
TN
MS AL
MO
IL
IA
MN
WI
LA
AROK
TX
KS
NE
ND
SD
HI
MT
WY
UT
CO
AZ
NM
IDOR
WA
NV
CA
AK
National Landscape
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Recommendations
Educate policy makers, primary and specialty
providers, and the public
Identify quality measures and reporting
strategies to improve access to and quality of
palliative care
Identify opportunities to align with delivery
system reforms and innovations
Define palliative care services and
standards; distinguish from
hospice
Develop strategies to build capacity
Develop sustainable reimbursement
Promote evidence-based standards and
practices across a variety of settings, and
across the lifespan
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Resources
’ Palliative Care: A Primer for State Policymakers
’ Advancing Palliative Care for Adults with Serious Illness: A National Review of State Palliative Care Policies and Programs Appendix A: Scan of State Regulations for Adult Palliative Care Activity Appendix B: Scan of State Medicaid Programs for Adult Palliative Care
’ Webinar: Advancing Palliative Care for Adults with Serious Illness: A National Review of State Palliative Care Policies and Programs
https://nashp.org/wp-content/uploads/2019/05/Palliative-Care-A-Primer-for-State-Policymakers.pdfhttps://nashp.org/wp-content/uploads/2018/12/Palliative-Care-Brief-Final.pdfhttps://nashp.org/wp-content/uploads/2018/12/NASHP_State-Palliative-Care-Scan_Appendix-A-New.pdfhttps://nashp.org/wp-content/uploads/2018/12/NASHP_State-Palliative-Care-Scan_Appendix-B-New.pdfhttps://nashp.org/wp-content/uploads/2018/12/NASHP-Palliative-Care-50-State-Scan-Webinar-Slides.pdf
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Increasing Access to Quality of Palliative Care: Laying the Groundwork
Dr. Martha Twaddle, Northwestern Medicine
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The Evolution and Expansion of Palliative Care in Health Care
The Integration of Palliative Care, Community and Population Health
Martha L. Twaddle MD FACP FAAHPM HMDC
Medical Director, Palliative Medicine & Supportive CareNorthwestern Medicine – North Region
Associate Professor of Medicine, Northwestern Feinberg School of Medicine
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This educational activity is being presented without bias or conflict of interest by the
planners and presenter.
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Objectives for This Discussion
• Discuss the continuum of Palliative Care – how it integrates with Population and Public health
approaches integral to healthcare re-alignment– and how it so effectively contributes the Triple Aim
• Discuss PC’s vital role in healthcare delivery systems to support the seriously ill through “community-based” models.
• Illustrate and consider models to integrate PC and its competencies into systems of care to avoid “chance encounters”.
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What is Palliative Care?• Palliative Medicine = Specialized medical
care for people with serious illness(es)• Palliative Care = Team-based
(interdisciplinary), focused on improving quality of life for patients AND their families by providing:Expert symptom managementEmotional and spiritual supportGuidance in navigating the healthcare systemAssistance with difficult medical decisions
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…What is Palliative Care?• Any serious diagnosis, particularly those that are
progressive and complex, or life-threatening• Any age• Any stage of illness• Team = Partnership with treating physicians &
clinicians• Extra layer of support and a care coordination• Provided alongside curative treatment
Palliative Medicine & Supportive Care
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Different from Hospice• Hospice is a form of palliative care supported by a
specific insurance benefit that people are eligible to use when they are terminally ill.
• Hospice provides palliative care for terminally ill patients with
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What population do we serve?How do we identify them?
Utilizing a method sensitive enough to identify most of the target population, but specific enough to focus on those who can benefit from supportive interventions. It is increasingly clear that any program’s ability to improve care value is critically reliant on targeting the right patients—not too many, not too few, but the right ones.
Meier 2016
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Beyond those who are dyingThe very illAging, frailtyChronically ill with debilityThe seriously ill for whom our health care
system is potentially rich with resources but who need help
navigating its fractured structure to make sense of all the choices – some of which are non-beneficial.
Our Population……
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Identifying those who need our care…
Inclusive of all people living with serious illness, regardless of setting, diagnosis, age or prognosis
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Serious Illness Definition A health condition that carries a high risk of mortality and either negatively impacts a person’s daily function orquality of life or excessively strains their caregiver.*
*Kelley, AS, Bollens-Lund, E. Identifying the population with serious illness: the “denominator” challenge. Journal of Palliative Medicine. Volume: 21 Issue S2: March 1, 2018.
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Systematic Approach
• …to caring for people with serious illness• Utilizing Population, Public, Community, Preventative Health
approaches• Right sized and matched to need • Scalable - Increasing the Populations served • Not just the patient, but the caregiver
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Palliative Care supports Population Based Health
“Sick”in hospital, facilities,
and home
Chronic
Well
PalliativeCare
Manage PopulationsWell = keep them well
Chronic = manage conditions
Well → Sick → WellWell → Sick → Palliative
Care
Wellness Services: Wellness Center Diet and Nutrition
Coaching Mammography Colonoscopy Psychiatry / Psychology Women’s Center Senior Center
The services and partnerships established in an integrated system of care meet the needs of the community throughout the entire health and wellness continuum.
Buxton; Twaddle 201428
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Caregiving Increases Mortality Risk
Nurses Health Study: prospective study of 54,412 nurses Increased risk of MI or cardiac death: RR 1.8 if
caregiving >9 hrs/wk for ill spouse Lee et al. Am J Prev Med 2003;24:113
Population based cohort study 400 in-homecaregivers + 400 controls Increased risk of death: RR 1.6 among caregivers
reporting emotional strain Schulz et al. JAMA 1999;282:2215.
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Impact on Hospital 30 DayRe-admissions
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Chart1
4081740817
4084840848
4087840878
4090940909
4094040940
4096940969
4100041000
4103041030
4106141061
4109141091
4112241122
4115341153
4118341183
4121441214
4124441244
4127541275
4130641306
4133441334
4136541365
4139541395
4142641426
PalCare
Hospital
Readmissions - Pal Care vs. Hospital (Medicare Only)
0.1650485437
0.1389221557
0.0943396226
0.1380880121
0.0569105691
0.1330343797
0.0720720721
0.14427157
0.0545454545
0.141025641
0.1545454545
0.1437908497
0.1313131313
0.1314102564
0.1440677966
0.1517241379
0.0775193798
0.1657060519
0.0697674419
0.1383458647
0.0775862069
0.1607142857
0.0588235294
0.1279620853
0.0862068966
0.1271753681
0.0654205607
0.0993690852
0.1181818182
0.1368267831
0.0878378378
0.1267605634
0.0526315789
0.1219512195
0.0490196078
0.126984127
0.0693069307
0.1169871795
0.0438596491
0.0981387479
0
0.1139240506
Dashboard
Palliative Care Dashboard - FY2012 and FY2013 through August
Dashboard
40817
40848
40878
40909
40940
40969
41000
41030
41061
41091
41122
41153
41183
41214
41244
41275
41306
41334
41365
41395
41426
41456
41499
% of Palliative Consults to Discharges
0.0539549502
0.0614136732
0.0652866242
0.0610561056
0.0605060506
0.0561797753
0.0582695703
0.0631016043
0.073630137
0.0748259861
0.067638484
0.06
0.0660968661
0.0644966847
0.0640279395
0.0792715587
0.074315515
0.0637101811
0.0634820867
0.0629370629
0.0582395764
0.0553745928
0.0560509554
Dashboard Data
41183
41214
41244
41275
41306
41334
41365
41395
41426
41456
41499
Inpatient Hospice Transitions (FY2013 only)
46
52
41
61
40
34
35
42
33
37
34
Graph for BOOST meeting
4081740817
4084840848
4087840878
4090940909
4094040940
4096940969
4100041000
4103041030
4106141061
4109141091
4112241122
4115341153
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4121441214
4124441244
4127541275
4130641306
4133441334
4136541365
4139541395
4142641426
4145641456
4149941499
ELOS Cases
% Pal Care
ELOS Cases
% Palliative Care
Extended LOS
30
0.2333333333
34
0.2058823529
34
0.1176470588
32
0.15625
32
0.21875
56
0.1785714286
42
0.2857142857
43
0.3953488372
34
0.3823529412
44
0.3863636364
46
0.2391304348
40
0.275
42
0.2380952381
58
0.1206896552
56
0.2857142857
60
0.2666666667
48
0.3333333333
49
0.306122449
60
0.25
45
0.2444444444
40
0.15
44
0.1363636364
44
0.1363636364
Dashboard - JC (Quality)
40817
40848
40878
40909
40940
40969
41000
41030
41061
41091
41122
41153
41183
41214
41244
41275
41306
41334
41365
41395
41426
41456
41499
Palliative Care Consults
103
106
123
111
110
110
99
118
129
129
116
102
116
107
110
148
114
102
101
99
88
85
88
Dashboard - JC (Operations)
4081740817
4084840848
4087840878
4090940909
4094040940
4096940969
4100041000
4103041030
4106141061
4109141091
4112241122
4115341153
4118341183
4121441214
4124441244
4127541275
4130641306
4133441334
4136541365
4139541395
4142641426
4145641456
4149941499
Benchmark
Rate
Benchmark
Hospital Mortality Rate
0.017
0.012
0.018
0.012
0.021
0.012
0.022
0.012
0.02
0.012
0.022
0.012
0.012
0.012
0.014
0.012
0.015
0.012
0.0117827869
0.012
0.0183673469
0.012
0.0220512821
0.012
0.018772
0.012
0.0137589433
0.012
0.0160771704
0.012
0.0276799195
0.012
0.0158054711
0.012
0.0239687848
0.012
0.0158013544
0.012
0.0106741573
0.012
0.0115606936
0.012
0.0172413793
0.012
0.0161559889
0.012
Dashboard - JC (Operations) (2)
Minev, Evgueni
Zimmerman, Karen
Strauch Do, Matthew
Damera, Madhukar
Coelho Md, Ian
Hai, Khola
Zerrudo, Joseph D
Shanley, John
Grzelak, Michael E
Galili Md, Doron
Referring MDs - by Order Authorize Provider Name (FY2013 only) [Excludes ED Referrals]
26
25
23
22
21
21
19
19
18
18
Old Dashboard Data
40909
40940
40969
41000
41030
41061
41091
41122
41153
41183
41214
41244
41275
41306
41334
41365
41395
41426
41468
41499
n=6
n=12
n=13
n=15
n=24
n=28
Family Survey Responses - Likelihood to Recommend(Surveys started Jan 2012)
1
1
1
1
1
1
1
1
1
1
1
1
0.875
1
0
1
0
0.8888888889
0.8
0
Graph - Hospice Discharges
4081740817
4084840848
4087840878
4090940909
4094040940
4096940969
4100041000
4103041030
4106141061
4109141091
4112241122
4115341153
4118341183
4121441214
4124441244
4127541275
4130641306
4133441334
4136541365
4139541395
4142641426
PalCare
Hospital
Readmissions - Pal Care vs. Hospital (Medicare Only)
0.1650485437
0.1389221557
0.0943396226
0.1380880121
0.0569105691
0.1330343797
0.0720720721
0.14427157
0.0545454545
0.141025641
0.1545454545
0.1437908497
0.1313131313
0.1314102564
0.1440677966
0.1517241379
0.0775193798
0.1657060519
0.0697674419
0.1383458647
0.0775862069
0.1607142857
0.0588235294
0.1279620853
0.0862068966
0.1271753681
0.0654205607
0.0993690852
0.1181818182
0.1368267831
0.0878378378
0.1267605634
0.0526315789
0.1219512195
0.0490196078
0.126984127
0.0693069307
0.1169871795
0.0438596491
0.0981387479
0
0.1139240506
PalCare vs. HospDisch
Palliative Care Dashboard Data Source
Palliative Care Consults as a % of DischargesPalliative Care Consults (excl Hospice)Hospice Discharges per Month (Hospital Wide)Pain Scores - Percentile RankPain Scores - Mean Score
Oct-115.40%Oct-11103Oct-1246QuarterICU9/PCQuarterICU9/PC
Nov-116.14%Nov-11106Nov-1252Q3 FY11064Q3 FY1189.483.8
Dec-116.53%Dec-11123Dec-1241Q4 FY117343Q4 FY1191.387.8
Jan-126.11%Jan-12111Jan-1361Q1 FY128277Q1 FY1292.590.2
Feb-126.05%Feb-12110Feb-1340Q2 FY122454Q2 FY1284.988.2
Mar-125.62%Mar-12110Mar-1334Q3 FY128618Q3 FY1293.285.3
Apr-125.83%Apr-1299Apr-1335Q4 FY128290Q4 FY1292.291.9
May-126.31%May-12118May-1342Q1 FY137062Q1 FY1390.688.7
Jun-127.36%Jun-12129Jun-1333Q2 FY138762Q2 FY1393.688.6
Jul-127.48%Jul-12129Jul-1337Q3 FY136733Q3 FY1392.486.9
Aug-126.76%Aug-12116Aug-1334
Sep-126.00%Sep-12102
Oct-126.61%Oct-12116
Nov-126.45%Nov-12107
Dec-126.40%Dec-12110
Jan-137.93%Jan-13148
Feb-137.43%Feb-13114
Mar-136.37%Mar-13102
Apr-136.35%Apr-13101
May-136.29%May-1399
Jun-135.82%Jun-1388
Jul-135.54%Jul-1385
Aug-135.61%Aug-1388
Hospital Mortality Rate - Benchmark = 0.012
Referring MDs -- by Order Authorize Provider Name (FY13 YTD)Survey Responses - Likelihood to RecommendMonthRateBenchmark
Minev, Evgueni26Jan-12100%Oct-110.0170.012
Zimmerman, Karen25Feb-12100%Nov-110.0180.012
Strauch Do, Matthew23Mar-12100%Dec-110.0210.012
Damera, Madhukar22Apr-12100%Jan-120.0220.012
Coelho Md, Ian21May-12100%Feb-120.0200.012
Hai, Khola21Jun-12100%Mar-120.0220.012
Zerrudo, Joseph D19Jul-12100%Apr-120.0120.012
Shanley, John19Aug-12100%May-120.0140.012
Grzelak, Michael E18Sep-12100%Jun-120.0150.012
Galili Md, Doron18Oct-12100%Jul-120.0120.012
Nov-12100%Aug-120.0180.012
Dec-12100%Sep-120.0220.012
Jan-1388%Oct-120.0190.012
Feb-13100%Nov-120.0140.012
Mar-13n/aDec-120.0160.012
Apr-13100%Jan-130.0280.012
May-13n/aFeb-130.0160.012
Jun-1389%Mar-130.0240.012
Jul-1380%Apr-130.0160.012
Monthly Extended LOS CasesAug-13n/aMay-130.0110.012
MonthELOS CasesELOS% Pal CareJun-130.0120.012
Oct-113020.8323.3%ReadmissionsJul-130.0170.012
Nov-113421.5020.6%MonthPalCareHospitalAug-130.0160.012
Dec-113419.2111.8%Oct-1116.5%13.9%
Jan-123219.1915.6%Nov-119.4%13.8%
Feb-123220.8421.9%Dec-115.7%13.3%
Mar-125623.0717.9%Jan-127.2%14.4%
Apr-124222.5528.6%Feb-125.5%14.1%
May-124319.8639.5%Mar-1215.5%14.4%
Jun-123421.0938.2%Apr-1213.1%13.1%
Jul-124419.8938.6%May-1214.4%15.2%
Aug-124624.4323.9%Jun-127.8%16.6%
Sep-124024.3827.5%Jul-127.0%13.8%
Oct-124223.7423.8%Aug-127.8%16.1%
Nov-125823.2112.1%Sep-125.9%12.8%
Dec-125619.9628.6%Oct-128.6%12.7%
Jan-136020.7026.7%Nov-126.5%9.9%
Feb-134820.8533.3%Dec-1211.8%13.7%
Mar-134924.3730.6%Jan-138.8%12.7%
Apr-136022.1025.0%Feb-135.3%12.2%
May-134523.4924.4%Mar-134.9%12.7%
Jun-134021.3815.0%Apr-136.9%11.7%
Jul-134427.4813.6%May-134.4%9.8%
Aug-134421.9113.6%Jun-130.0%11.4%
Referral DaysCompleted Same DayCompleted Next DayCompleted 2+ Days
Apr-1368342
May-1365211
Jun-1358322
Jul-1349201
Aug-137792
Referral DaysAprilApril %MayMay %JuneJune %JulyJuly %AugAug %
Completed Same Day6865.4%6574.7%5863.0%4970.0%7787.5%
Completed Next Day3432.7%2124.1%3234.8%2028.6%910.2%
Completed 2+ Days21.9%11.1%22.2%11.4%22.3%
# of Referrals104100.0%87100.0%92100.0%70100.0%88100.0%
n=13
n=1
n=4
n=8
n=6
n=10
n=8
n=3
n=0
Completed Same Day
Completed Next Day
Completed 2+ Days
Referral Completions by Day
41365
41365
41365
41395
41395
41395
41426
41426
41426
41456
41456
41456
41499
41499
41499
68
34
2
65
21
1
58
32
2
49
20
1
77
9
2
n=1
n=0
n=9
n=15
n=0
Graph - ELOS
Graph - ELOS
4081740817
4084840848
4087840878
4090940909
4094040940
4096940969
4100041000
4103041030
4106141061
4109141091
4112241122
4115341153
4118341183
4121441214
4124441244
4127541275
4130641306
4133441334
4136541365
4139541395
4142641426
PalCare
Hospital
Readmissions - Pal Care vs. Hospital (Medicare Only)
0.1650485437
0.1389221557
0.0943396226
0.1380880121
0.0569105691
0.1330343797
0.0720720721
0.14427157
0.0545454545
0.141025641
0.1545454545
0.1437908497
0.1313131313
0.1314102564
0.1440677966
0.1517241379
0.0775193798
0.1657060519
0.0697674419
0.1383458647
0.0775862069
0.1607142857
0.0588235294
0.1279620853
0.0862068966
0.1271753681
0.0654205607
0.0993690852
0.1181818182
0.1368267831
0.0878378378
0.1267605634
0.0526315789
0.1219512195
0.0490196078
0.126984127
0.0693069307
0.1169871795
0.0438596491
0.0981387479
0
0.1139240506
Graph - # of Consults
Palliative Care -- Quality Dashboard
Graph - # of Consults
Q3 FY11Q3 FY11
Q4 FY11Q4 FY11
Q1 FY12Q1 FY12
Q2 FY12Q2 FY12
Q3 FY12Q3 FY12
Q4 FY12Q4 FY12
Q1 FY13Q1 FY13
Q2 FY13Q2 FY13
Q3 FY13Q3 FY13
ICU
9/PC
Percentile Rank
Palliative Care"How well was your pain controlled?"
0
64
73
43
82
77
24
54
86
18
82
90
70
62
87
62
67
33
Graph - Mortality Rate
Palliative Care -- Operations Dashboard
n = 13
n = 1
n = 4
ICU
9/PC
Mean Score
Palliative Care"How well was your pain controlled?"
Q3 FY11
Q3 FY11
Q4 FY11
Q4 FY11
Q1 FY12
Q1 FY12
Q2 FY12
Q2 FY12
Q3 FY12
Q3 FY12
Q4 FY12
Q4 FY12
Q1 FY13
Q1 FY13
Q2 FY13
Q2 FY13
Q3 FY13
Q3 FY13
89.4
83.8
91.3
87.8
92.5
90.2
84.9
88.2
93.2
85.3
92.2
91.9
90.6
88.7
93.6
88.6
92.4
86.9
n = 8
n = 6
Family Survey Responses - Likelihood to Recommend(Surveys started Jan 2012)
40909
40940
40969
41000
41030
41061
41091
41122
41153
41183
41214
41244
41275
41306
41334
41365
41395
41426
41468
41499
1
1
1
1
1
1
1
1
1
1
1
1
0.875
1
0
1
0
0.8888888889
0.8
0
Graph - Mortality Rate
40817
40848
40878
40909
40940
40969
41000
41030
41061
41091
41122
41153
41183
41214
41244
41275
41306
41334
41365
41395
41426
41456
41499
% of Palliative Care Consults to Discharges
0.0539549502
0.0614136732
0.0652866242
0.0610561056
0.0605060506
0.0561797753
0.0582695703
0.0631016043
0.073630137
0.0748259861
0.067638484
0.06
0.0660968661
0.0644966847
0.0640279395
0.0792715587
0.074315515
0.0637101811
0.0634820867
0.0629370629
0.0582395764
0.0553745928
0.0560509554
40817
40848
40878
40909
40940
40969
41000
41030
41061
41091
41122
41153
41183
41214
41244
41275
41306
41334
41365
41395
41426
41456
41499
Palliative Care Consults
103
106
123
111
110
110
99
118
129
129
116
102
116
107
110
148
114
102
101
99
88
85
88
41183
41214
41244
41275
41306
Inpatient Hospice Transitions (FY2013 only)
46
52
41
61
40
Palliative Care -- Operations Dashboard
40817
40848
40878
40909
40940
40969
41000
41030
41061
41091
41122
41153
41183
41214
41244
41275
41306
41334
41365
41395
41426
41456
41499
% of Palliative Care Consults to Discharges
0.0539549502
0.0614136732
0.0652866242
0.0610561056
0.0605060506
0.0561797753
0.0582695703
0.0631016043
0.073630137
0.0748259861
0.067638484
0.06
0.0660968661
0.0644966847
0.0640279395
0.0792715587
0.074315515
0.0637101811
0.0634820867
0.0629370629
0.0582395764
0.0553745928
0.0560509554
40817
40848
40878
40909
40940
40969
41000
41030
41061
41091
41122
41153
41183
41214
41244
41275
41306
41334
41365
41395
41426
41456
41499
Palliative Care Consults
103
106
123
111
110
110
99
118
129
129
116
102
116
107
110
148
114
102
101
99
88
85
88
40909
40940
40969
41000
41030
41061
41091
41122
41153
41183
41214
41244
41275
41306
41334
41365
41395
41426
41456
41499
% of Palliative Care Consults to Discharges
0.0610561056
0.0605060506
0.0561797753
0.0582695703
0.0631016043
0.073630137
0.0748259861
0.067638484
0.06
0.0660968661
0.0644966847
0.0640279395
0.0792715587
0.074315515
0.0637101811
0.0634820867
0.0629370629
0.0582395764
0.0553745928
0.0560509554
40909
40940
40969
41000
41030
41061
41091
41122
41153
41183
41214
41244
41275
41306
41334
41365
41395
41426
41456
41499
Palliative Care Consults
111
110
110
99
118
129
129
116
102
116
107
110
148
114
102
101
99
88
85
88
41183
41214
41244
41275
41306
Inpatient Hospice Transitions (FY2013 only)
46
52
41
61
40
OLD DASHBOARD DATA
Palliative Care Consults by Hospital Service (YTD FY12)Referring MDs -- by Attending MD (FY12 YTD)
CAR9718%1Baker, Richard38
GAS92%2Minev, Evgueni26
MED29254%3Shapiro, Aleksandr24
NEU438%4Grzelak, Michael21
NSR10%5Tan, Kelly19
ONC6412%6Hai, Khola18
ORT71%Longo, Robert18
PUL71%Santa, Edwin18
SUR214%9Sunkari, Amar17
URO10%Zerrudo, Joseph17
54211Goode, Galina16
9S LOS (All Pts)FY12 YTD - Critical Care Referrals (2S/CC)464
Oct-114.71
Nov-115.07
Dec-115.03
Jan-124.60
Feb-124.52
Hospice Discharges
MonthFY2009FY2010FY2011FY2012FY2013
Oct1518181746
Nov2219131452
Dec2927161141
Jan23192416
Feb14252710
Mar19182010
Apr36202018
May24221313
Jun22151217
Jul24181821
Aug1120717
Sep15131328
FY2009
FY2010
FY2011
FY2012
FY2013
Hospice Discharges
Palliative Consults vs. Hospital Discharges
MonthPalliative Care Consult NumberHospital Discharges% of Pal Care to Disch
May-101121360.51%
Jun-102521801.15%
Jul-103122031.41%
Aug-104921342.30%
Sep-104521952.05%
Oct-105022142.26%
Nov-105719862.87%These all need to be fixed based on new report qualifiers in Clinical Query
Dec-105921612.73%
Jan-1110022244.50%
Feb-119519524.87%
Mar-1112621465.87%
Apr-119220054.59%
May-1111720035.84%
Jun-1110018865.30%
Jul-1111319325.85%
Aug-119018684.82%
Sep-1110919115.70%
Oct-1110319095.40%
Nov-1110617266.14%
Dec-1112318766.56%
Jan-1211118186.11%
Feb-1211018186.05%
Mar-1211019585.62%
Apr-129916995.83%
May-1211818706.31%
Jun-1212917527.36%
Jul-1212917247.48%
Aug-1211617156.76%
Sep-12
% of Pal Care to Disch
% of Palliative Consults to Discharges
Extended LOS Cases
MonthELOS Cases% Pal Care
Oct-10549.3%
Nov-103630.6%
Dec-103613.9%
Jan-115812.1%
Feb-113821.1%
Mar-113228.1%
Apr-113520.0%
May-113525.7%
Jun-113727.0%
Jul-113023.3%
Aug-114219.0%
Sep-113023.3%
Oct-113023.3%
Nov-113420.6%
Dec-113411.8%
Jan-123215.6%
Feb-123221.9%
Mar-125617.9%
Apr-124228.6%
May-124339.5%
Jun-123438.2%
Jul-124438.6%
Aug-124623.9%
&A
Page &P
ELOS Cases
% Pal Care
ELOS Cases
% Palliative Care
Number of Conults Trended
Month# of Consults
Jun-1025
Jul-1031
Aug-1049
Sep-1045
Oct-1052
Nov-1059
Dec-1051
Jan-1184
Feb-1176
Mar-1197
Apr-1165
May-1185
Jun-1171
Jul-1183
Aug-1159
Sep-1186
Oct-1167
Nov-1170
Dec-1184
Jan-12111
Feb-12110
Mar-12110
Apr-1299
May-12118
Jun-12129
Jul-12129
Aug-12116
# of Consults
Hospital Mortality Rate
MonthBenchmarkMortality Rate
Jun-100.0120.015
Jul-100.0120.014
Aug-100.0120.013
Sep-100.0120.009
Oct-100.0120.013
Nov-100.0120.017
Dec-100.0120.019
Jan-110.0120.022
Feb-110.0120.017
Mar-110.0120.018
Apr-110.0120.017
May-110.0120.015
Jun-110.0120.020
Jul-110.0120.013
Aug-110.0120.017
Sep-110.0120.012
Oct-110.0120.017
Nov-110.0120.018
Dec-110.0120.021
Jan-120.0120.022
Feb-120.0120.020
Mar-120.0120.022
Apr-120.0120.012
May-120.0120.014
Jun-120.0120.015
Jul-120.0120.012
Aug-120.0120.018
Trendline
Benchmark
Mortality Rate
Benchmark
-
Changing the Epicenter to the Community
Func
tion
Death
(CHF, COPD often coupled with DM, ESRD etc)
Low
Multiple hospitalizations Death usually follows disease exacerbation
HighHospital
RehabHome Health
Repeat
CPC Time frame – particularly targeting the last year of life.
CbPC
34
-
Community-based Palliative Care (CbPC)
Func
tion
Death
Low
Multiple hospitalizations Death usually follows disease exacerbation
HighHospital
RehabHome HealthHome Health
Home Health
Hospice Care
Office Visits
CbPC
CbPC Time frame – particularly targeting the last year or two of life.
35
-
Supportive Model for Cancer Care
Func
tion
Death
Low
Onset of illness Decline usually 3 months
"Cancer" Trajectory, Diagnosis to DeathHighHome Health
Office Visits
Hospice Care
CbPC
-
Early Palliative Care for Patients with Metastatic Non-Small
Cell Lung Cancer
Temel JS et al. N Engl J Med 2010;363:733-742
-
• Early ambulatory palliative care, in conjunction with life-sustaining treatments, for patients with metastatic NSCLC is associated with:– Improved mood– Improved QOL– More documentation of code status– Less aggressive EOL care– Improved survival
The Results
-
Medical Home Coordinated Care Model FeaturingPalliative Med / Advanced Illness Services Component
Twaddell & Twaddle 2011
-
Neighborhood: Home-based Primary & Palliative CarePopulation Health, PCMH@Home &
PCMH@Home Neighbor
HEALTH STATUS STRATIFICATION
Data and Analytics• Claims• Rx• Lab• Referrals• Pt. Records• ER Admits• Performance
Low-Risk Patients (Acute episodic care / routine health maint)
Medium-Risk Patients
(Multiple chronic diseases)
High-Risk Patients (Chronic disease unstable or changing
/ recently hospitalized)
Home-based Primary Care (PCMH@Home)• Personal Provider
• Interdisciplinary Team• Longitudinal or Transitional Care
Home-based Palliative Care (PCMH@Home Neighbor)
• Consultation or Co-management for high symptom burden or advanced disease
• Longitudinal specialty palliative care
Patient Centered Medical HomeAmbulatory Practice
Patient Outcomes Clinical Pathways - Routine - Intake preventative services - Triage for same day care
Specialty Services
High Intensity Care
Management
Functional Limitations
Multiple Chronic Conditions
HCN*
*HCN=healthcare navigatorRitchie, Twaddle 2015
41
-
Kelley 2014; Meier 2016
-
1-year
outcomes
Not Seriously Ill
(or “Comparison
group”)
Category A
Serious condition
and/or functional
impairment
Category B
Serious condition
and/or functional
impairment AND
utilization
Category C
Serious condition
AND functional
impairment AND
utilization
Number of
Subjects6,280 5,297 3,151 1,447
Hospitalization 12% 33% 44% 47%
Total Medicare
costs (mean)$7,789 $20,566 $26,349 $30,828
Mortality 2% 13% 19% 28%
-
• improving the experience of care, • improving the health of populations, and • reducing per capita costs of health care.
Berwick DM, Nolan TW, Whittington, J. Health Aff May 2008 vol. 27 no. 3 759-769.
44
Improving the U.S. Health Care System Requires Simultaneous Pursuit of Three Aims:
https://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&docid=NhzafaA_1oGb3M&tbnid=7KNmZuLSDD5lKM:&ved=0CAUQjRw&url=https://www.crowdcontent.com/blog/2012/09/17/who-is-your-target-audience/&ei=HZZRU6TYNqia8AHFjoHYDA&bvm=bv.65058239,d.b2U&psig=AFQjCNEjRSyP9TmFE4AriJkK3wTV2gRQGA&ust=1397942055162304
-
Palliative Care is Uniquely Effective in Achieving the Triple Aim
Outcomes of Palliative Care:• Reduction in symptom burden• Care concordant with pt/family wishes• Improved patient and family satisfaction• Reduced costs
45Copyright 2008 Center to Advance Palliative Care. Reproduction by permission only.
https://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&docid=NhzafaA_1oGb3M&tbnid=7KNmZuLSDD5lKM:&ved=0CAUQjRw&url=https://www.crowdcontent.com/blog/2012/09/17/who-is-your-target-audience/&ei=HZZRU6TYNqia8AHFjoHYDA&bvm=bv.65058239,d.b2U&psig=AFQjCNEjRSyP9TmFE4AriJkK3wTV2gRQGA&ust=1397942055162304
-
46
-
2300% increase in US healthcare spending per capita between 1970-2009
-
Stiefel M: IHI; 2012. (www.IHI.org)
-
Transforming 21st Century Care of Serious IllnessChange from: Change to:Terminal Advanced ChronicPrognosis weeks-month Prognosis months to yearsCancer Condition (frailty, fn’l dep, MCC)Disease All chronic progressive diseasesMortality PrevalenceCure vs. Care Synchronous shared careDisease OR palliation Disease AND palliationPrognosis as criterion Need as criterionReactive Screening, PreventiveSpecialist Palliative/Geriatric Care/Generalist
levelInstitutional Community
No regional planning Public health approachFragmented care Integrated care
Gomez-Batiste et al. 2012
-
Importance of Palliative Care
Interdisciplinary team expertise• Support for transitions of care for high risk
patients across sites of care • Active care management to meet patients and
families needs and thus prevent unnecessary inpatient/ED utilization
• Filling gaps in existing community services – or coordinating the gaps
-
The 4th edition• For all people with serious illness,
regardless of setting, diagnosis, prognosis, or age
• Increased attention to caregiver strain• Screening and assessment in all Domains• Attention to the vulnerability of the
seriously ill when moving across settings of care.
• Funded by the Gordon and Betty Moore Foundation
• Published by the National Coalition for Hospice and Palliative Care
• NCP leadership consisted of 16 national organizations
• Endorsed by almost 90 National Organizations like ACS, AHA, AMA….
-
Population Health + Pal Care
Potent opportunity for health care delivery systems, public health agencies, community-based organizations, and many other entities to work together to improve health outcomes in the communities they serve.
M. Stoto, Academy Health 2013
For the seriously ill – PC interdisciplinary teams may serve as population health integrators
-
Miguel McInnis, MPH
-
Canadian Diabetes Assoc
-
• improving the experience of care, • improving the health of populations, • improving the work life of health care
providers, including clinicians and staff, and • reducing per capita costs of health care.
Berwick DM, Nolan TW, Whittington, J. Health Aff May 2008 vol. 27 no. 3 759-769. 59
Improving the U.S. Health Care System Requires Simultaneous Pursuit of Three Four Aims:
https://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&docid=NhzafaA_1oGb3M&tbnid=7KNmZuLSDD5lKM:&ved=0CAUQjRw&url=https://www.crowdcontent.com/blog/2012/09/17/who-is-your-target-audience/&ei=HZZRU6TYNqia8AHFjoHYDA&bvm=bv.65058239,d.b2U&psig=AFQjCNEjRSyP9TmFE4AriJkK3wTV2gRQGA&ust=1397942055162304
-
Summary• Palliative Care is uniquely effective in meeting the
Triple Aim for seriously ill people and their families.• PC has a vital role in contributing to the development
of Population and Public Health (Community Health) approaches in healthcare models.
• PC’s expertise as an interdisciplinary model is relevant and of great value as a Population Health Integrator.
• It is imperative that we know who we are here to serve – that our truth north is caring for seriously ill people and their families.
• It is imperative as well that we are supported and sustained in this vital work.
-
Break10:30-11:00am
-
Building Effective Delivery Systems: Sustainable Reimbursement Models
Torrie Fields, Blue Shield of CaliforniaAnastasia Dodson, California Department of Healthcare Services
-
Lessons learned (so far) from developing and implementing home-based palliative care
Torrie Fields, MPH, Senior Manager, Blue Shield of California
-
Blue Shield of California
The challenge• Millions of Americans live with serious illness…a group that is expected to double
in the next 25 years. • Young or old, they can live for many years or only months. • While diverse, they will require extensive care at various points in their illness.• Programs to serve them are not widely available or well-coordinated.
How we will meet it• Blue Shield provides eligible members high-quality palliative care that helps
those with serious illness receive the care they want and need.
The challenge we can meet together
-
Blue Shield of California
Palliative care = great care and good business
CAPC- https://www.capc.org/tools-for-making-the-case/downloadable-tools/
Meets the “Triple Aim” • Improving patient experience of care (including quality and satisfaction)• Improving the health of populations• Reducing health care costs
https://www.capc.org/tools-for-making-the-case/downloadable-tools/
-
Blue Shield of California
Blue Shield’s palliative care program summaryImproving the lives of people with serious illness.
California state-wide provider network
• More than 40 contracted home-based palliative care programs, across all California counties
• Outpatient palliative care programs in all metropolitan service areas
• Telemedicine-enabled palliative care programs for rural members
• Inpatient palliative care programs in all tertiary hospitals
Results
2,000+ families served from 2017-2018
95% patient satisfaction
Palliative Care Program Overview
• Palliative Care Case Management Program• Caregiver Support• Advance Care Planning• Referrals to community-based palliative care
providers• Personal Care Services for Trio ACO Members
-
Blue Shield of California
• Services• Help with pain and other problems• 24/7 access to help and support• Help with making treatment decisions and arranging medical care • Help with coordinating medical care and communicating with doctors• Support for the family • Meal delivery and transportation, in some cases
• Settings- Throughout California wherever the person needs or wants• In their home• In clinics in all metropolitan areas• In all large hospitals• Via phone or video in rural areas• In many nursing homes
Blue shield’s palliative care program
-
Blue Shield of California
• Specially-trained:• Doctors• Nurses• Social workers• Chaplains• Home health aides• Other specialists
Who’s on Blue Shield’s palliative care team?
-
Blue Shield of California
General Criteria Diagnosis Criteria• Have a serious illness• Have documented gaps in care,
including decline in health status and/or function
• Use hospital and/or ER to manage illness • Not currently enrolled in hospice• Illness is NOT psychiatric or substance use
disorder-related
• Included but not limited to:• Cancer• Organ failure (e.g., heart, lung, renal, liver)• Stroke• Neurodegenerative disease (e.g., MS,
ALS)• HIV/AIDS• Dementia/Alzheimer’s• Frailty or advanced age• Multiple comorbid conditions with
exacerbated pain
Palliative care patient eligibility criteria
Palliative care is a standard medical service offered to all members with primary Blue Shield coverage except those who carry FEP PPO, Shared Advantage, or
Medicare supplemental insurance (Medigap).
-
Blue Shield of California
• Team-based approach is fragmented• Integration of different agencies in IDT• Issues with data sharing and transfer of charting• Organizational names can be a deterrent to patient and physician,
strengthening bond between palliative care and hospice• Palliative care is often a second service line under another type of
licensure that can restrict provision of care by provider (ex. CA SB 294)
• Sustainability• Development of a financial model for providers that works with other
value-based payment models• Funding is difficult to secure for evaluation of new models
• Replication• Commercial implementation without market share• Need to streamline reimbursement and coding for providers• Need to streamline clinical and operational requirements
Overcoming Barriers to Adaptation
-
Blue Shield of California
Payment for Palliative Care Comes in Many Forms
-
Blue Shield of California
Quality Incentive Payments Provide Even More Flexibility
Incentive Model DescriptionShared Savings Splitting total cost of health care savings
based on quality percentage payouts
Quality lump sum payment
Per beneficiary payment based on overall practice performance
Fee-for-service tier enhancements
Increasing the percent of Medicare payment based on quality scores
-
Blue Shield of California
• Quality measures and/or actual spending are used at least in part to determine the amount a provider is paid
• Many VBPs are add-ons built on a FFS architecture – bonuses, penalties, and/or reconciliations happen at the end of each time period
Payment is Shifting Beyond FFS to “Value-Based Payment (VBP)”
-
Blue Shield of California
• Measures should be negotiated with private payers• Limit the use of performance measures to only those your program can influence• Performance measures should be balanced between:
• Cost and Utilization• Patient and Family Satisfaction• Quality of Care
• Ensure targets account for the level of illness in this population• Resource can will be high• Satisfaction is low when the patient feels sick
• Limit the administrative burden of data collection and reporting• Suggest using existing Registries
Setting Performance Measures and Targets
-
Blue Shield of California
• Single monthly payment for a defined set of services• Often requires 24/7 availability• Onus on palliative care program to stratify their patient population to manage service delivery
within fixed payments• Often need to find operational efficiencies (e.g., telehealth, “outsourcing”)• Does not necessarily require taking on additional risk
Prevalent APM is the “Case Rate” Payment
-
Blue Shield of California
• Blue Shield has established aper member per month (PMPM) case rate to support the Program’s interdisciplinary team approach.
• Members in the Program are not charged copays or coinsurance for services provided as part of the Program.
• Members are also flagged in Blue Shield’s internal systems to expedite coordination and authorization of services they may need.
Value-Based Payment Improves Quality
77
-
Blue Shield of California
Licensure and other regulatory barriers can limit capacity of providers to provide this service.
Enrollment growth is slow and building relationships takes time Referral sources must be varied to account for low enrollment or
exposure to these types of services. People often don’t know what palliative care is
Innovative hospices and home health agencies are best positioned to provide home-based palliative care, due to setting and team composition
Implementation is slow and other barriers will arise• Applying hospice regulations to your palliative care program• Change from per diem to care coordination• Lack of exposure to commercial plans & contracting• Slower than average pace for contracting and payment, utilization management
The start-up cost of a program is much greater than the sustainable cost, when enrollment growth stabilizes the practice. Start-up support must be considered
Summary and Lessons Learned
-
Blue Shield of California
-
Palliative Care in California’s Medicaid Program
Anastasia Dodson, Associate DirectorCalifornia Department of Health Care ServicesNASHP Conference, August 2019
-
• New State Law: Senate Bill 1004• Policy Development & Data Analysis• Stakeholder Engagement and Partnership• Provider Training• Implementation
81
Presentation Overview
-
• California Senate Bill (SB) 1004 signed by Governor Brown in 2014
• Required the California Department of Health Care Services (DHCS) to “establish standards and provide technical assistance for Medi-Cal managed care plans to ensure delivery of palliative care services.”
82
New State Law
-
• Leverage Existing Palliative Care Models in California• Research Coding, Conditions, Services, Fiscal
Impact, Results• Consider Managed Care and Fee-for-Service Delivery
Systems• Began Policy Development in 2015, with
Implementation in 2017
83
Policy Development
-
84
SB 1004 Care Model
Design adapted from the National Consensus Project for Quality Palliative Care.*POLST: Physician’s Orders for Life Sustaining Treatment
-
• Cancer (28.2%)• Injury/Accidents (15.6%)• Heart disease (14.4%)• Liver disease (6.4%)• Stroke (3.9%)• Diabetes Mellitus (3.4%)• Chronic lower respiratory disease (3.3%)• Influenza/pneumonia (1.6%)• Other diseases not included above (23.2%)
85
Most Frequent Causes of Death for Medi-Cal only* Decedents in 2013
*Excludes Dually Eligible Medicare-Medi-Cal Beneficiaries
-
0
200
400
600
800
1000
1200
1400
13 - 18 months 7 - 12 months Within 6 months
Num
ber o
f Dec
eden
ts
Months Prior to Death
Hospital Inpatient Utilization AmongAugust 2015 Medi-Cal only Decedents (1,237 individuals)
Decedents Without Inpatient Admissions in Specified PeriodDecedents With Inpatient Admissions in Specified Period
86
Inpatient Utilization
-
87
Emergency Department Visits
0
200
400
600
800
1000
1200
1400
13 - 18 months 7 - 12 months Within 6 months
Num
ber o
f Dec
eden
ts
Months Prior to Death
Emergency Department Visits AmongAugust 2015 Medi-Cal Decedents (1,237 individuals)
Decedents with ED Visits in Specified PeriodDecedents without ED Visits in Specified Period
-
• Four eligible conditions, and patient must meet both General and Disease-Specific Criteria for any of these conditions:– Cancer– Congestive Heart Failure (CHF) – Chronic Obstructive Pulmonary Disease (COPD)– Liver Disease
• These four conditions are the minimum; Medi-Cal managed care plans (MCPs) may authorize palliative care for patients with other conditions.
88
SB 1004 Eligible Conditions
-
1. Advance Care Planning2. Palliative Care Assessment and Consultation3. Plan of Care4. Pain and Symptom Management5. Mental Health and Medical Social Services6. Care Coordination7. Palliative Care Team8. Chaplain Services9. 24/7 Telephonic Palliative Care Support
(recommended)• Access to Curative Care/Disease Modifying Care
89
SB 1004 Palliative Care Services
-
Palliative Care Service Billing CodesAdvance Care Planning (Inpatient/Outpatient [I/O] and Hospital [H])
Evaluation and Management (E&M) codes 99497 (reimbursable twice a year before Treatment Authorization Request [TAR] override) & 99498 (reimbursable once a year before TAR override)
Palliative Care Assessment and Consultation (I/O)
E&M codes for counseling
Palliative Care Assessment and Consultation (H)
E&M codes 99341 – 99350 for MD/NP, or Home health for RN/LPN
Pain and Symptom Management (I/O) Prescription drugs, physical therapy (TAR)
Pain and Symptom Management (H) Home health physical therapy
Mental Health Services, Discharge Planning (I/O)
Individual and group psychotherapy, hospital or Nursing Facility Level B discharge planning
Mental Health Services and Caregiver Assessment/Support (H)
Medical social services within home health
Plan of Care (I/O) E&M codesPlan of Care (H) Home health or E&M codes 99341 – 99350
Care Coordination (I/O) E&M codesCare Coordination (H) Home health or E&M codes 99341 – 99350
Palliative Care Team (I/O) E&M codes 99366 and 99368Palliative Care Team (H) Home health or E&M codes 99341 – 99350 90
Palliative Care Billing Codes
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• DHCS SB 1004 Website and Email: [email protected]
• Draft policy paper posted for public comment
• Several Stakeholder Meetings in 2015 and 2016
• Discussions with Providers, Managed Care Plans, Researchers, Advocates
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Stakeholder Engagement and Partnership
mailto:[email protected]
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• California Health Care Foundation (CHCF): Wide range of online materials and resources, as well as grants and in-person technical assistance events.
• Coalition for Compassionate Care of California:Consumer and provider resources on advance care planning and palliative care. Also frequent webinars and training programs.
• California State University, Institute for Palliative Care:Instructor-led and self-paced online training for health care professionals, as well as patients and families.
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Stakeholder Engagement and Partnership (cont’d)
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• Broad need for more training, in both:– Primary Palliative Care– Specialty Palliative Care
• State Budget in 2017-18 and 2018-19 included funds for provider training in palliative care.
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Provider Training
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• Policy launched January 1, 2017 in Fee-for-Service and Managed Care Delivery Systems– Provider Bulletin with Codes– Managed Care All-Plan Letter– Managed Care Plan Palliative Care Start-Up
Funding
• Managed Care Plan Performance Measures and Results– Collecting Provider Participation Info, and
Referrals and Enrollment/Disenrollment Data– Results similar to other palliative care
programs94
Implementation
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• California Department of Health Care Services, SB 1004 Website: https://www.dhcs.ca.gov/provgovpart/Pages/Palliative-Care-and-SB-1004.aspx
• Medi-Cal Provider Bulletin: http://files.medi-cal.ca.gov/pubsdoco/newsroom/newsroom_26508.asp
• Medi-Cal Managed Care All-Plan Letter: https://www.dhcs.ca.gov/formsandpubs/Documents/MMCDAPLsandPolicyLetters/APL2018/APL18-020.pdf
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Resources
https://www.dhcs.ca.gov/provgovpart/Pages/Palliative-Care-and-SB-1004.aspxhttp://files.medi-cal.ca.gov/pubsdoco/newsroom/newsroom_26508.asphttps://www.dhcs.ca.gov/formsandpubs/Documents/MMCDAPLsandPolicyLetters/APL2018/APL18-020.pdf
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Questions?
Thank you!
Contact: [email protected]
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Building Effective Delivery Systems: Quality and Capacity Building
Pete Liggett, South Carolina Department of Health and Human ServicesDr. Doug Fish, New York State Department of Health
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Medicaid, Healthcare Integration& Palliative Care
Pete Liggett, Ph.D., Licensed PsychologistDeputy Director, Long Term Living
South Carolina Department of Health & Human Services
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• The South Carolina Medicaid program does not expressly cover a benefit titled, “Palliative Care”
• However, dually eligible (Medicare/Medicaid) can access palliative care through their Medicare benefit – for FFS beneficiaries this is difficult to navigate
• Our Medicare-Medicaid Plan MCOs cover palliative care for duals as D-SNPs using the Medicare benefit
• SC has approximately 92,000 “Duals”• 15,000 enrolled in our duals demonstration • 1.1 million beneficiaries total
Palliative Care Benefit
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• Services can be cobbled together for any Medicaid beneficiary meeting medical necessity for…
• Not yet hospice level• Pain management• Behavioral and mental health services• Incontinence Supplies• Home Health• Children’s Private Duty Nursing• Community Choices 1915(c) Home & Community Based Services Waiver (e.g.,
Personal Care, Environmental Mods, Respite, etc.)• Any other state plan services
How does Palliative Care Happen
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• Palliative Care was introduced in our Duals Demo as a “New” benefit under the demonstration.
• Center for Advanced Palliative Care provided input on messaging of benefit in 2018 member material to promote quality of life
• Prior Language included: “Advanced illness” “Life-threatening injury” “End-of-life”
• New Language includes: Specialized medical care for “people with serious illnesses” Goal is to “improve quality of life for both the patient and family” Provides “extra layer of support” to patient’s doctors “Appropriate at any stage of serious illness”; can be “provided together with curative
treatment”
How does Palliative Care Happen
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• Palliative care is not a well understood healthcare construct in South Carolina because it is not expressly covered.
• Providers• Beneficiaries
• Palliative care IS understood by a limited number of palliative care providers who stay busy with a limited patient load
• Palliative care has had strong advocacy from the pediatrics community
Challenges
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• Hospice becomes the bundled treatment of choice• …and is supposed to include an array of services including personal care and
other HCBS-like services.
• However…• The Hospice benefit is state plan only and is an MMP carve-out• For 1915(c) participants, they cannot receive many of the most popular
services (e.g., personal care, adult day health care, respite)
• Beneficiaries must weigh the pros and cons of using hospice.
The Jump to Hospice
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• H. 4935 created the “Palliative Care and Quality of Life Study Committee.”
• Exploring the state of palliative care in SC including:• Education/training for healthcare professionals• Resources for the public• Services and care settings• Reimbursement
• By December 31, 2019, the study committee shall submit to the Governor and the General Assembly a report on the state of palliative care in South Carolina with findings and recommendations.
Going Forward
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August 2019
Integrating Palliative Care in Delivery SystemsNew York State DSRIP Palliative Care Projects
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Agenda
August 2019
• Introduction to NYS Delivery System Reform Incentive Payment (DSRIP) Program • Overview of Palliative Care Projects
• Project Design• Assessment• Key Takeaways
• Promising Practices• United Hospital Fund Report and Performing Provider System (PPS) Examples
• Palliative Care & Value Based Payment
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New York State DSRIP Program
August 2019
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The 2014 MRT Waiver Amendment and New York State’s DSRIP Goals
August 2019
• In April 2014, Gov. Andrew M. Cuomo announced that New York State and CMS finalized the MRT Waiver Amendment
• Allowed the State to reinvest $8 billion of $17.1 billion in Federal savings generated by MRT reforms
• $6.4 billion designated for fulfilling DSRIP Goals: Reduce avoidable hospital admissions and emergency
department use by 25% over the next 5 years Preserve and transform the State’s healthcare safety net
system
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August 2019
25 DSRIP Performing Provider Systems (PPS)
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Each PPS was able to select between 5 and 11 projects across 3 domains*
August 2019
Domain 2: System Transformation Projects• Create Integrated Delivery Systems focused on Evidence-Based Medicine
and Population Health Management• Care transitions intervention model to reduce 30 day readmissions for
chronic health conditions
Domain 3: Clinical Improvement Projects• Integration of primary care and behavioral health services• Evidence-based strategies for disease management in high risk/affected
populations
Domain 4: Population-Wide Projects• Strengthen Mental Health and Substance Use Disorder Infrastructure
across Systems• Promote tobacco use cessation, especially among low socioeconomic
status populations and those with poor mental health
Applicants chose Minimum 2, Maximum 4
Projects
Applicants chose Minimum 2, Maximum 4
Projects
Applicants chose Minimum 1, Maximum 2
Projects
Applicants chose between
5 and 11 Projects
*Project 2.d.i is described as “Implementation of patient and community activation activities to engage, educate and integrate the uninsured and low/non-utilizing Medicaid populations into community based care,” which PPSs could select as their 11th project.
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Integration of Palliative Care into the PCMH Model (3.g.i)• Alliance for Better Health Care• Central New York Care Collaborative• Leatherstocking Collaborative Health Partners• Adirondack Health Institute• OneCity Health• Community Care of Brooklyn• The New York and Presbyterian Hospital• Care Compass Network• Community Partners of Western New York
Integration of Palliative Care into Nursing Homes (3.g.ii)• Staten Island PPS• The New York and Presbyterian
Hospital/Queens
August 2019
11 PPS Chose a Palliative Care Project
“Palliative care…is an integrated specialty, it’s not another swim lane, so to speak.”
~ Martha L. Twaddle, MD1
1 Abbasi, J New Guidelines Aim to Expand Palliative Care Beyond Specialists. JAMA. 2019;322(3):193-195. doi:10.1001/jama.2019.5939
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Palliative Care ProjectsProject 3.g.i: Integration of Palliative Care into the PCMH ModelProject 3.g.ii: Integration of Palliative Care into Nursing Homes
August 2019
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Palliative Care Projects’ Aim & Measure• Projects aim to further integrate palliative care into patient-centered medical
home (PCMH) practices and nursing home settings. • A tool was selected to measure access to palliative care services for patients
most in need, not to evaluate the outcomes associated with palliative care interventions.
• Both projects use the Integrated Palliative Care Outcome Scale (IPOS), a standardized screening tool to identify which patients are most in need of palliative care interventions.
August 2019
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• Require project managers to identify & engage appropriate providers;
• Develop partnerships with community-based resources;
• Develop and/or adopt clinical guidelines agreed to by all partners;
• Train staff to increase role-appropriate competence in palliative care skills;
• Engage with Medicaid Managed Care to address coverage of services; and
• Monitor progress through a quality committee.
August 2019
Palliative Care Project Requirements… this secondary goal drove several project implementation requirements including to:
Beyond increasing access, the project seeks to drive provider organizations to find the “right patient” in order to…• Reduce burden – not all high-cost/high-need patients
need palliative care
• Emphasize the use of screening tools, many of which can draw from data in the Electronic Health Record
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History of Measure Selection• Initial measure choice was Uniform Assessment System – NY (UAS-NY), but
an issue was identified early on:• Very little overlap between PPS target population for Palliative Care and the
population captured in UAS-NY Long-Term Care and Community-Based programs
• Measures available in UAS-NY addressed pain management, depression, and advanced directives, but did not include other areas relevant to goals for palliative care. The assessment also took 4 hours to complete per patient
• Updated the measure, choosing the IPOS• The state needed a mechanism through which standardized data could be
captured, results could be accounted for, & incentive dollars could be paid out.• A literature search was performed, and the POS tools emerged as most closely
aligning with program intents.
August 2019
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Why the Integrated Palliative care Outcome Scale (IPOS)?• What is the tool?
• A 10-item questionnaire to assess patient’s physical symptoms, psychological, emotional, and spiritual needs
• Widely used in palliative care projects across the US and internationally
• Moving from POS to IPOS• DOH collaborated with the Cicely Saunders Institute to better understand the benefits of IPOS
• Greater focus on symptom identification & less emphasis on look-back period
• Correlation between the survey tool and P4P measure• Three questions measure across four domains in projects 3.g.i and 3.g.ii, and a fifth (Pain) was
added:• Physical symptoms• Depression• Peacefulness• Completion of advance directives
August 2019
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Crosswalk between POS/IPOS & Project Measures
August 2019
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IPOS ImplementationVersions• Two of the three versions of the IPOS acceptable:
• the patient version (self-administered or administered by a family member/caregiver) and
• the staff versionFrequency of administration• After baseline established, assessments should be conducted at least every six
months• Assessments should be additionally administered when a patient:
• Enters a palliative care treatment regimen (or as soon as possible if already participating)
• Experiences a significant change in patient status (defined as changes to the patient’s care plan, such as hospitalization, changes in home care needs, independent living status)
August 2019
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Implementation Timeline
August 2019
Pay
for P
erfo
rman
cePa
y fo
r Rep
ortin
g • July 1, 2016 to June 30, 2017• Began collecting baseline data (start of *MY3Q3) to establish
baseline for MY4• Six months of data needed to ensure implementation progress
• July 1, 2017 to June 30, 2018• Ratio must improve for Pay-for-Performance (P4P) Achievement
Values (AVs) to be earned
MY4
*MY3
• July 1, 2018 to June 30, 2019• Ratio must improve for P4P AVs to be earnedM
Y5
Audit Protocol:
• During MY3-5 PPS must audit 10% of all completed assessments
• Self-audit done - if lower than 75% accuracy, a full audit of all completed assessments by the independent assessor would be triggered
*MY - Measurement Year
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A Forum for Shared Learning was Established
The Center for Advanced Palliative Care (CAPC) and the
Hospice and Palliative Care Association of New York State (HP-CANYS)
established a DSRIP Palliative Care Forum
• Convene PPSs implementing 3.g projects• Share challenges, solutions, lessons learned• Provide resources to support implementation• Highlight NYS Hospices’ available expertise• Draw on best practices in other parts of the country
August 2019
• Telephone town-halls and discussion groups
• Webinars to share best practice and implementation efforts
• Program updates and policy changes
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August 2019
Assessing Project Progress
Q2. Below is a list of symptoms, which you may or may not have experienced. For each symptom, please tick one box that best describes how it has affected you over the past week:
Q5. Have you been feeling depressed?
Q6. Have you felt at peace?
Q11. Check all advance directives known to have been completed:
Performance Questions
Assessment Method and AVs
• Five measures: Pain (Q2), Physical symptoms (Q2), Depression (Q5), Peacefulness (Q6), and completion of advance directives(Q11) align with an IPOS question
• Numerator is # of patients offered or provided an intervention for the “symptom”
• Denominator is # of patients whose response to the assessment indicated the need for such intervention
• Achievement Value is earned if ratio of current measurement year result to baseline is greater than 1
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IPOS Measure Results July 2016 – June 2018 (MY3 – MY4)• All 5 measures improved at statewide level• All 11 PPS earned Achievement Value indicating improvement on at least one of
the measures
August 2019
0.69 0.680.62
0.430.40
0.850.80
0.86
0.77
0.67
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
Pain(Q2)
PhysicalSymptoms
(Q2)
Depression(Q5)
Peacefulness(Q6)
AdvanceDirectives
(Q11)
MY32534 Surveys
MY45358 Surveys
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Project Key Takeaways• PCMH can be an opportune setting to identify those patients most appropriate for
palliative care• Patient has an established relationship with a trusted provider• PCMH focuses on cultural competency and health literacy, especially
important for sensitive palliative care consultations • Resources are in place (care coordinators/managers) to manage care plans
• Need to be realistic about the time needed to engage in dialogue on palliative care and advance directives
• Access to Medicare claims data needed to analyze full benefit• Misconceptions persist
• Some may view a palliative care referral as an indication that the treatment (or the treating provider) has failed
• On-going patient and provider education is needed
August 2019
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Promising Practices & Paying for Value-Based Care
August 2019
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August 2019
UHF Report on DSRIP Promising Practices
Press Release: NEW YORK, NY—July 16, 2019—Four years into a groundbreaking overhaul of its Medicaid program, New York has laid the groundwork for improving health care access, quality, and costs well beyond 2020 if it continues to expand on the practices implemented to date, according to a report released today by United Hospital Fund (UHF) and funded by the New York State Department of Health.
Link to full press release: https://uhfnyc.org/news/article/nys-medicaid-reform-efforts-can-improve-health-care-outcomes-well-beyond-2020/
Link to report: DSRIP Promising Practices: Strategies for Meaningful Change for New York Medicaid - https://uhfnyc.org/publications/publication/dsrip-promising-practices/
https://uhfnyc.org/news/article/nys-medicaid-reform-efforts-can-improve-health-care-outcomes-well-beyond-2020/https://nam02.safelinks.protection.outlook.com/?url=https://uhfnyc.org/publications/publication/dsrip-promising-practices/&data=01|01|[email protected]|fb751a2bea5144a1432608d70ec9c710|d9b110c34c254379b97ae248938cc17b|0&sdata=g3p%2BDfX3QVkwDGFXzG8SbZqsG7XIdrSwOz0E3EKSgFg%3D&reserved=0
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NY Presbyterian Queens PPS1• Partnership between New York Presbyterian Queens PPS and Silvercrest Nursing Home
• Silvercrest’s hospital readmission rate was one of the highest among the 27 SNFs that formed the PPS’ long-term care committee. The committee sought to improve readmission rates and other long-term care related quality metrics.
• Implemented a Palliative Care educational program using CAPC modules and in person sessions with NPs to educate patients, families and providers at Silvercrest.• Increased awareness and understanding of “Goals of Care consultations” and
relevance of such consultations to reducing readmissions.• Developed SNF protocols for common clinical decisions around evaluation, management,
and transport and by implementing more systematic palliative care referrals. • The PPS reports that, as a result of these activities, Silvercrest’s hospital readmission
rate decreased from 31% (in January-March 2018) to 23% (in April-November 2018)
August 2019
1 New York Presbyterian Queens PPS. February 2019. DSRIP Learning Symposium Poster. Available at: http://www.dsriplearning.com/documents/presentations/posters/RPPH23_Hospital%20and%20Skilled%20Nursing%20Facility%20Collaboration%20to%20Reduce%20Palliative%20Services%20Related%20Readmissions.pdf
http://www.dsriplearning.com/documents/presentations/posters/RPPH23_Hospital%20and%20Skilled%20Nursing%20Facility%20Collaboration%20to%20Reduce%20Palliative%20Services%20Related%20Readmissions.pdf
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State University of New York (SUNY) Upstate MAX Project2• SUNY Upstate anchors the Central New York Care Collaborative (CNYCC) PPS• MAX = “Medicaid Accelerated Exchange” model for rapid cycle continuous
improvement• Project focused on high utilizers
• Unmet palliative care needs were found to be a driver of high utilization• Developed care pathways that included warm-handoffs to Health Homes,
home care agencies, and other community partners, and developed improved process for inpatient palliative care referrals
• From March to May of 2017, reduced high utilizer inpatient admissions by 15%
August 2019
2 New York State Department of Health. 2018. MAX Series Case Studies, January-July 2017. Available at https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/pps_workshops/max/docs/2017-jan-jul_max_case_studies.pdf
https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/pps_workshops/max/docs/2017-jan-jul_max_case_studies.pdf
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New York State (NYS) Payment ReformVBP PilotsTowards 80% of Provider Payments based on Value
Today
April 2017 April 2018 April 2019 April 2020> 10% of total Managed
Care Organization (MCO) expenditure in Level 1
VBP or above
> 50% of total MCO expenditure in Level 1
VBP or above.> 15% of total payments contracted in Level 2 or
higher *
80% of total MCO expenditure in Level 1
VBP or above> 35% of total payments contracted in Level 2 or
higher *
Performing Provider Systems (PPS)
requested to submit growth plan outlining path
to 80-90% VBP
2017 2018 2019 2020
Palliative Care and Value Based Payment
August 2019
• Financial incentives provided through DSRIP have increased access to palliative care.• Palliative Care would be incorporated into a value-based payment model.
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August 2019
Questions
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Douglas G. Fish, MDMedical DirectorDivision of Medical and Dental Directors
New York State Department of HealthOffice of Health Insurance ProgramsOne Commerce Plaza, Suite 720Albany, NY 12237Phone: [email protected]
mailto:[email protected]
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State Strategies for Promoting Palliative Care and Increasing Awareness
Stacie Sinclair, Center to Advance Palliative CareGinny Weir, Bree Collaborative
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Increasing Access to Palliative Care –Current Landscape and Opportunities
Stacie Sinclair, MPP, LBSWSenior Policy ManagerCenter to Advance Palliative Care
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About CAPC➔ The Center to Advance Palliative Care (CAPC) is a national,
member-based organization that supports hospitals, health systems, hospices, payers, and other health care organizations with the implementation and integration of palliative care
➔We do this by:– Providing training, tools, and technical assistance– Serving as a convening, organizing, and dissemination force for the field– Promoting public awareness of palliative care– Collecting and providing essential metrics
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Our Strategies to Scale Palliative Care Access Nationwide
➔ Operational Training
➔ Clinical Training
➔ Research
➔ Payment
➔ Policy
➔ Public Awareness
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Palliative Care Barriers➔ It is estimated that fewer than 5% of people living with a serious illness
who could benefit actually receive care informed by palliative care principles and practices
➔ Barriers include:– Lack of training of frontline clinicians in the core skills of communication,
symptom management, and family support over time– Unreliable financing– Deficits in the specialist workforce– Persistent misunderstanding of palliative care– Lack of oversight, particularly in home-based palliative care
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Starting Point: Messaging Palliative CareCAPC Public-Facing Definition Supported by Public Opinion
Research
National Consensus Project Definition CMS Definition
Palliative care (pronounced pal-lee-uh-tiv) is specialized medical care for people living with a serious illness. This type of care is focused on providing relief from the symptoms and stress of a serious illness. The goal is to improve quality of life for both the patient and the family.
Palliative care is provided by a specially-trained team of doctors, nurses and other specialists who work together with a patient’s other doctors to provide an extra layer of support. Palliative care is based on the needs of the patient, not on the patient’s prognosis. This care is appropriate at any age and at any stage in a serious illness, and it can be provided along with curative treatment.
Interdisciplinary care delivery system designed for patients, their families and caregivers
Beneficial at any stage of a serious illness
Anticipates, prevents, and manages physical, psychological, social, and spiritual suffering to optimize quality of life
Delivered in any care setting through the collaboration of many types of care providers
Improves quality of life for both the patient and the family through early integration into the care plan
“Palliative care” means patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and to facilitate patient autonomy, access to information, and choice.
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Key Challenge – Messaging Palliative Care (2011)General Public➔ Majority of public does not know what
palliative care is; from 2011 polling:– Plurality of adults 25+ did not recognize the term– Phrase “palliative care and supportive services”
viewed more positively than “palliative care” alone
– Often confused with “hospice” and “end-of-life care”
– How palliative care is defined has a big impact on how people feel about palliative care
➔ Once informed, 92% of consumers felt positively about palliative care and reported a high likelihood of wanting to access if they or a loved one had a serious illness
Clinicians➔ Also have misconceptions regarding
palliative care and end-of-life care (“You’re not ready for palliative care”); alternately– Think services are limited to advance care
planning or pain clinic services– Think they are already providing this kind of
care– Limited understanding of how palliative care
can contribute➔ Leads to late or inappropriate referrals➔ Requires persistence, data on referred
patient outcomes (time-consuming)
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2019 National Survey - Methodology
➔National telephone survey: A total of 800 adults age 25+ oversampling to reach n=347 65+ years
➔National online survey: 252 patients with a serious illness and 262 family caregivers of patients with serious illness
➔National online survey: 317 physicians who treat patients with serious illness (207 hospital-based/110 non-hospital-based)
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2019 National Survey – Public➔Palliative care is still relatively unknown
among the general public
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2019 National Survey – Public➔ Initial impressions of palliative care are
positive to neutral➔Patients and caregivers report higher levels
of familiarity than the general public
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2019 National Survey – Public➔ Sub-groups least familiar with palliative care are men, rural residents, those in
lower income households and with lower levels of education. Those sub-groups who have the most favorable opinion of palliative care initially are older women and adults with higher levels of education.
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Top Sub Groups –Unable to Rate Palliative Care (Adults)
(38%)Men Less than College 50%Men Income Less than $60K 46%High School or Less 45%No Serious Illness in Household 44%Rural 44%Some College 44%Republicans 44%Income $40K-$60K 44%Men 43%
Top Sub Groups –% Rating 80-100 Palliative Care
(Adults)(19%)
Post Graduates 34%Women Ages 45-64 28%Women College+ 27%Women Ages 65+ 26%Republican Women 26%Women 24%Homemakers 24%Pacific Region 24%Strong Democrats 24%Retired 23%
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2019 National Survey – Public➔Use of the previous definition has a
significant positive impact on how the public feels about palliative care
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2019 National Survey – Public➔More than eight in ten consumers say they
would be likely to consider palliative care for themselves or a loved one if they had a serious illness.
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2019 National Survey – Public➔ After hearing the palliative care definition, substantial
majorities of consumer audiences agree with these premises about palliative care:
145
%Total Agree – Ranked by Patients
Adults Ages 25+
Adults Ages 65+ Patients Caregivers
Palliative care treatment options should be fully covered by health insurance. 90% 90% 96% 93%
It is important that patients with a serious illness and their families be educated that
palliative care is available to them together with curative treatment.
97% 93% 96% 93%
Doctors who treat patients with a serious illness should refer these patients to
palliative care when the patient is experiencing difficult-to-manage pain or
other symptoms
87% 86% 94% 93%
Palliative care should be available to patients with a serious illness based on a
patient’s need, not based on their prognosis.
87% 87% 93% 90%
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2019 National Survey – Public ➔Palliative care messages that score well with the public:
– Providing the best quality of life– Relief from symptoms, pain, and stress– Appropriate at any age and providing the care alongside curative
treatment– Matching treatment options to patient goals– A team approach to care– Providing an extra layer of support
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2019 National Survey – Public
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2019 National Survey – Public➔ Data continue to show that palliative care should be positioned as care for patients
with serious illness but NOT advanced illness. Advanced illness is perceived to be more closely aligned with terminal illness
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13% 13% 12% 25%
85% 85% 88% 75%
25+ 65+ Patients Caregivers
37% 37% 38% 44%60% 56% 52% 56%
25+ 65+ Patients CaregiversYes No
Serious Illness
Advanced Illness
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2019 National Survey – Public ➔How we talk about palliative care influences perceptions
of palliative care➔Attitudes become significantly more favorable as people
are educated➔The more educated consumers become, the more likely
they are to say they would consider palliative care for themselves or a loved one (this is particularly true among patients and caregivers)
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2019 National Survey – Physicians
➔Physicians who treat patients with serious illness are much more familiar with palliative care and have much more favorable views of palliative care than the general public, patients and caregivers.
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2019 National Survey – Physicians ➔Unfortunately, downstream referral criteria:
– Illness no longer curable, or no viable treatment options available – the priority is comfort
– Patient has a prognosis of less than six months– Patient has a terminal illness– Patient has frequent hospitalizations or ICU stays– If they ask for palliative care– When pain medications are no longer effective– When a patient has worsening symptoms or heart failure
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2019 National Survey – Physicians
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1st Choice Combined ChoicePatients not wanting palliative care 17% 40%
Physicians not being comfortable talking with patients and families about palliative care 17% 41%
Physicians view palliative care as ONLY end of life care 14% 44%Lack of or inadequate palliative care services and professionals available 10% 31%
Lack of awareness about what palliative care options are available for patients 10% 31%Competing treatment priorities, needing to address and treat serious illness
first 9% 25%Lack of knowledge about the criteria used to determine when to refer patients
to palliative care 6% 25%Lack of knowledge and familiarity with palliative care 6%